Summary Report for FSPSAs Ending During the Report Period Statewide
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs ending between: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 24689 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 285 291 1526.227769 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 66 66 11232.496826 $417848.8800 $37.2000
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Subtotal (Total Children Is Unduplicated) 350 357 12758.724595 $417848.8800 $32.7500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 139 162 116.197378 $5635.5600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 25 26 19.269330 $1081.0100 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 266 298 316.126985 $6167.6400 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 15 15 15.000000 $355.0500 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 21 21 17.266590 $253.4700 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 90 91 50.941553 $1124.2800 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 18 19 15.155554 $109.1200 $7.2000
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 9 9 9.000000 $94.0500 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 18 18 14.222221 $411.3000 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 11 12 12.000000 $540.9600 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 28 28 23.838888 $329.2100 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 20 21 31.428571 $661.2600 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 1.000000 $61.0000 $61.0000
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 146 154 154.000000 $11570.0200 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 18 20 17.822223 $807.7100 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 5 2.509818 $290.6700 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 23 29 35.549925 $1777.5000 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 6 7 10.219178 $510.9600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 46 46 69.520994 $3476.0500 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 9 12 22.205556 $1665.4200 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 23 24 46.005479 $3450.4100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 11 11 21.000000 $1575.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 10 10 20.000000 $1500.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 8 16.000000 $1200.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 22 22 36.172602 $2007.5800 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 7 7 12.000000 $666.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 252 258 495.829546 $37187.2300 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 136 137 254.088737 $19056.6500 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 63 63 121.500000 $9112.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 30 30 56.005479 $4200.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 86 87 168.785714 $12658.9300 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 77 77 127.043833 $9528.2900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 357 363 700.110499 $38856.1400 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 185 187 335.170057 $18601.9400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 259 334 659.000000 $49425.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 94 116 229.071429 $17180.3600 $75.0000
MED -99202 OUTPATIENT VISIT, NEW, 20 MINS 1 1 0.177778 $9.2200 $51.8600
MED -99204 OUTPATIENT VISIT, NEW, 45 MINS 1 1 0.888889 $99.4900 $111.9200
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 9 9 9.911112 $1409.6700 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 3 7.533333 $376.6700 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 9 9 28.800000 $1440.0000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 83 85 33.576190 $1726.1500 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.216667 $11.1400 $51.4200
OCTH -97165 OT EVAL LOW COMPLEXITY 141 157 142.457936 $7323.7700 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 6 7 1.955556 $100.5400 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 34 34 18.929147 $973.1500 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 2 2 0.327777 $16.8500 $51.4000
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 119 124 79.869860 $4106.0900 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 5 5 2.288890 $117.6800 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 6 6 1.056165 $54.3000 $51.4200
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 3 3 10.285714 $528.7900 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 51 52 29.786506 $1531.3100 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 2 2 0.238889 $12.2800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 50 53 29.150741 $1498.6500 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 4 4 1.438888 $73.9700 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 25 25 16.274583 $836.6900 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 80 88 33.968950 $1746.3600 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.505556 $25.9900 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 3 3 1.605556 $82.5400 $51.4100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 2 2 1.022222 $52.5500 $51.4100
SCREEN-T1023 SCREENING 25 25 24.533333 $1226.6700 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 0.986301 $14.9000 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 151 175 145.429266 $7476.5100 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.377778 $19.4200 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 10 10 2.833334 $145.6700 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 14 14 13.869634 $713.0400 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 1.811111 $93.1100 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.022222 $1.1400 $51.3600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 223 235 104.801412 $5387.8300 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 3.555556 $182.7900 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 5.066667 $260.4800 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 1.819482 $93.5400 $51.4100
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 2 2 1.366667 $70.2600 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 16 17 7.651751 $343.2600 $44.8600
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.8600 $44.8600
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.8600 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 7 7 32.571429 $1724.0100 $52.9300
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Subtotal (Total Children Is Unduplicated) 2390 3932 5078.020987 $306933.3000 $60.4400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 85 90 75.717516 $378588.0000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 15 15 15.005935 $750.2900 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.811111 $56.2500 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 4.180822 $289.9400 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 22 22 17.857611 $4136.1800 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 856 1058 874.434073 $43721.8200 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 75 83 52.930300 $2646.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 189 215 173.081902 $4327.0500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1197 1357 2018.324979 $100916.1600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 63 66 104.077777 $5203.8900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 83 90 99.007859 $2475.1900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 936 1044 1255.646033 $62782.3000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 21 22 26.666666 $1333.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 51 88 85.549207 $2138.7300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 438 492 616.376720 $30818.7700 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 25 26 27.283334 $1364.1700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 16 29 24.622222 $615.5600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1282 1346 1641.425382 $82071.1900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 54 55 68.988890 $3449.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 79 83 96.005555 $2400.1400 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 22 24 398.999998 $9975.0100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 126 140 973.499997 $24337.5200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 667 762 5461.667081 $273083.3800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4328 4663 27156.810402 $1357840.1100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 352 379 2089.325413 $104466.2400 $50.0000
INTR -T1013 INTERPRETER 177 214 527.684053 $26384.2000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2637 3525 16923.353973 $169233.4700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 654 743 4184.040497 $301083.4600 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 17 19 113.219048 $8147.2500 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 106 112 787.776590 $45375.9700 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 16.285714 $938.0600 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 50 52 252.449209 $18166.2400 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 9.571428 $688.7600 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 613 714 3618.306360 $260373.1100 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 9 9 33.147619 $2385.3000 $71.9600
PHY -97110HM PT SESSION BY PT ASST 48 52 310.472224 $17870.7700 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 2 8.785714 $505.7100 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 48 52 181.658728 $13072.1400 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 5 5 46.714286 $3361.5500 $71.9600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 1 9.714286 $559.1600 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 3.142857 $180.9100 $57.5600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 0.164384 $18.8700 $114.8200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.150685 $34.6000 $229.6300
SENS -V5060 BEHIND EAR HEARING AID 3 3 3.000000 $688.8300 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 7 7 4.672223 $2145.6100 $459.2300
SENS -V5264 EARMOLD 14 14 9.343152 $169.3900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 943 1097 6658.459671 $479142.5600 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 28 28 144.230953 $10378.8600 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.350000 $20.1600 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 2.428571 $139.8900 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 56 60 318.193650 $22897.2100 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 9 9 43.200000 $3108.6700 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 8 11 38.428571 $536.4600 $13.9600
TRAV -TRAVS Travel by mile 1033 1506 81995.867851 $36488.1600 $0.4500
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Subtotal (Total Children Is Unduplicated) 7028 20400 159603.109082 $3923882.4600 $24.5900
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Total 24689 177439.854664 $4648664.6400 $26.2000
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Number of Children (Unduplicated) With at Least One Authorization 8217